HospitalInspections.org

Based on visual observation, the facility failed to provide positive latching doors to 2 of 8 smoke compartments. This deficiency if not corrected could have the opportunity to cause harm to 40 of the 44 patients in the facility.



FIndings: During tour of facility on 4-5-11 between 9:30 AM and 3:00 PM, the dining room and board room doors were observed not to have positive latching devices installed on them.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on visual observation the facility failed to provide a manual release device identified by a sign that reads PUSH TO EXIT at 2 of the 13 exit doors. This deficiency if not corrected could have the potential to cause harm to 10 of the 44 patients and anyone in the front lobby area.

Findings: During tour of building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the front door from the lobby and the ER ambulance exit door were observed having access control locks installed on them. These locks have a sensor to detect occupants so the doors will open to exit, but a code must be entered to access the door from the outside. NFPA Life Safety Code allows this type of locking for security proposes but must meet the following requirements.
7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock ? independent of the access control system electronics ? and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on visual observation the facility failed to provide ashtrays of safe design and self closing cover devices into which ashtrays could be emptied in 3 of 3 designated smoking areas. This deficiency if not corrected could have the potential to harm those 44 of the 44 patients in the building.

Findings: During tour of the building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the 3 designated smoking areas, by plant operations, C wing gazebo, and the ER ambulance drive thru area were observed having the "genie type" cigarette receptacles. NFPA 101 Life Safely Code requires the following type of ashtrays were smoking is allowed.

Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on visual observation the facility failed to provide a exit discharge that was of a reliable and firm surface leading to a public way in 1 of 13 exit discharge routes. This deficiency if not corrected could have the potential to cause harm to 15 of the 44 patients in the building.

Findings: During tour of building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the C wing exit discharge was observed as a 15 foot concrete pad. Beyond this concrete pad is grass to the public way which is approximately 50 feet. If the C wing would have to be evacuated wheelchairs and beds could sink and become stuck if the area were to become muddy after rains.

Based on visual observation, the facility failed to provide positive latching doors to 2 of 8 smoke compartments. This deficiency if not corrected could have the opportunity to cause harm to 40 of the 44 patients in the facility.



FIndings: During tour of facility on 4-5-11 between 9:30 AM and 3:00 PM, the dining room and board room doors were observed not to have positive latching devices installed on them.

19.3.6.3.2*
Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Based on visual observation the facility failed to provide a manual release device identified by a sign that reads PUSH TO EXIT at 2 of the 13 exit doors. This deficiency if not corrected could have the potential to cause harm to 10 of the 44 patients and anyone in the front lobby area.

Findings: During tour of building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the front door from the lobby and the ER ambulance exit door were observed having access control locks installed on them. These locks have a sensor to detect occupants so the doors will open to exit, but a code must be entered to access the door from the outside. NFPA Life Safety Code allows this type of locking for security proposes but must meet the following requirements.
7.2.1.6.2 Access-Controlled Egress Doors.
Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock ? independent of the access control system electronics ? and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on visual observation the facility failed to provide ashtrays of safe design and self closing cover devices into which ashtrays could be emptied in 3 of 3 designated smoking areas. This deficiency if not corrected could have the potential to harm those 44 of the 44 patients in the building.

Findings: During tour of the building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the 3 designated smoking areas, by plant operations, C wing gazebo, and the ER ambulance drive thru area were observed having the "genie type" cigarette receptacles. NFPA 101 Life Safely Code requires the following type of ashtrays were smoking is allowed.

Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Based on visual observation the facility failed to provide a exit discharge that was of a reliable and firm surface leading to a public way in 1 of 13 exit discharge routes. This deficiency if not corrected could have the potential to cause harm to 15 of the 44 patients in the building.

Findings: During tour of building on 4-5-2011 between 9:30 a.m. and 3:00 p.m. the C wing exit discharge was observed as a 15 foot concrete pad. Beyond this concrete pad is grass to the public way which is approximately 50 feet. If the C wing would have to be evacuated wheelchairs and beds could sink and become stuck if the area were to become muddy after rains.